Get Attending Physician S Statement New Application - Public Health Oregon

Completing the attending physician's statement for the Oregon Medical Marijuana Program is essential for registration. This guide provides step-by-step instructions to assist users in filling out the form accurately and efficiently.

Follow the steps to complete the application with ease.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient information. Fill in the patient's name (last, first, and middle initial), date of birth, mailing address, telephone number, and their city, state, and zip code. Ensure all information is legible.
3. Next, proceed to the physician information section. Enter the physician's name, their medical doctor (MD) or doctor of osteopathy (DO) number, mailing address, telephone number, and city, state, and zip code. Accuracy is important to verify the physician's credentials.
4. In the physician's statement section, check all applicable boxes indicating the patient's debilitating medical conditions. This includes conditions such as malignant neoplasm (cancer), glaucoma, HIV/AIDS, agitation due to Alzheimer’s Disease, PTSD, or other medical conditions that may lead to severe symptoms.
5. Complete the comments section if any additional information is pertinent to the patient's condition. Ensure the physician certifies their information by signing in the provided space. This signature confirms the physician's authority and responsibility for the patient's care.
6. Finally, enter the date of completion and ensure that the attending physician's statement is mailed to the correct address provided in the instructions. Users may download, print, or share the completed form as needed.

Complete your application online to ensure a smooth registration process.